| First Name | |
| Last Name | |
| Address | |
| City | |
| State | |
| Zip | |
| Phone | |
| Email | |
Have you ever volunteered at RRMC or an Affiliate of RRMC in the past? |
| If no leave blank, if yes, when? |
Have you ever volunteered at RRMC or an Affiliate of RRMC in the past under a different name? |
| If yes, please specify: |
When are you available? |
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Are you 14years of age or older? |
| If not, when will you reach 14? |
Have you (since the age of 18) been convicted of a felony? |
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Please give dates and describe the circumstanes surrounding the conviction. Note that a conviction
will not necessarily bar you from a volunteer position.
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Have you been involuntarily discharged from a volunteer position? |
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Please give dates and describe the circumstanes surrounding the discharge.
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Please describe your educational background including
Name of school attended, Dates, Graduation date, as well as any degree or majors your pursued and/or completed. |
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List all previous work experience here including
Position, Responsibilities, Hours Worked, Date of Employment, Name of supervisor,
Address, Phone Numbers, Dates of Employment and Reason for leaving. |
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Please give three references we may contact to verify your qualifications.
(Teens please include your Guidance Counselor as one of your references) |
| Name | Title and Phone | Organization and Address |
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Are you required to perform compulsary or community service? |
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How did you find out about the Volunteer Program at RRMC? |
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Affidavit |
I certify that the answers given by me to the foregoing questions and statements are true and
correct. I agree that I will not claim or hold Rutland Regional Health Services in any respect
if my volunteerism is terminated because of the falsity of statements, answers or omissions made
by me in this questionnaire. I authorize employers, companies, schools or persons named above to
give any information regarding my employment or volunteerism, together with any information they
may have regarding me whether or not it is in their records. I hereby release said employees,
companies, schools or persons from all liability for any damage, both legal and otherwise, for
issuing this information. I also understand a conditional offer of a volunteer position may be
based on results of a later medical examination. In addition, if accepted for the volunteer program,
I hereby agree to abide by the rules and policies of Rutland Regional Health Services.
Further, I understand that any volunteer position is at will and is not for a stated
period of time and may be terminated with or without cause, at any time, at the option of either
myself or my employer. I also understand, acknowledge and agree that my volunteer position is not
subject to any RRHS/RRMC handbook, and since I am holding the position at will, I can be released
from that position at any time for any reason.
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